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Vol. 28 No. 3 - The Benefits of a Balanced Diet

By Hillary Sachs, MS, RD, CSO, CDN
North Shore-LIJ’s Cancer Institute, Great Neck, NY

Originally published in Pathways (Winter 2014), Canadian Lymphedema Framework. Reprinted with permission.

Click here to download a pdf. 

As an oncology dietitian, I often see how a cancer diagnosis leaves people with a lost sense of control. The risk, development, and progression of lymphedema can also leave those afflicted feeling helpless. The good news is that there are several researched dietary factors that may modify the risk and progression of lymphedema, such as fluid, protein and sodium intake, anti-inflammatory dietary patterns, immune boosting foods, weight history, and
current body mass index (BMI). 

How does lymphedema manifest?

Lymphedema manifests in many ways that can affect a person’s nutrition and overall health. Some symptoms of lymphedema may impact one’s ability to carry out tasks related to food preparation. For example, pain may limit the ability to independently shop for groceries or carry and unpack bulky food items. Leg lymphedema may be made worse by standing in one place for long periods of time to chop and prepare food, or upper extremity compression garments, such as gloves or gauntlets, may interfere with food preparation. 

Nutritional interventions: sodium

Surprisingly, there is not much research that directly links sodium to lymphedema. However, we do know that in the human body, water tends to follow salt. Thus, excess salt intake can cause water to be drawn into blood vessels, increasing pressure on arterial walls, and worsening swelling. In addition, high sodium foods are generally more processed, devoid of nutrients, and less healthy. The following are just a few common foods naturally high in sodium:

    • Cottage cheese
    • Bread
    • Baking soda
    • Shellfish
    • Deli meat
    • BBQ sauce
    • Cheese

Strategies to decrease sodium intake

Dramatically cutting out salt in the diet will generally result in less palatable foods. However, taste buds adapt to the taste of less salt over time. To increase compliance, it is recommended to reduce total daily salt intake by ¼ tsp or 600 mg at a time until optimal daily intake levels are reached. 

Strategies to help reduce sodium intake

    • Eat more fresh, single ingredient foods
    • Eat more homemade foods
    • Buy fresh/frozen meat with no added sodium
    • Buy whole grain rice/pasta plain without seasonings and add your own!
    • Make soups on your own; use extra onion, carrots, and celery for flavor
    • Replace salt in recipes with other herbs and spices
    • Rinse canned foods

Nutritional interventions: protein intake 

Lymph fluid contains a large amount of protein in the form of albumin, so it is not surprising that people assume
that REDUCING protein intake may DECREASE lymph fluid. However, this is NOT the case. In fact, optimal protein intake is necessary to help repair skin and keep connective tissue strong. Moreover, it is important to replenish protein stores since some protein is lost in the fluid. 

Protein needs in lymphedemalymphedema nutrition chart

Protein requirements for the average person with lymphedema are generally: 

    • 100 lb person needs about 45-55 grams of protein per day
    • 125 lb person needs about 57-68 grams 
    • 150 lb person needs 68-82 grams
    • 175 lb person needs about 80-95 grams

Protein needs increase with:

  • increased age
  • muscle wasting
  • sores
  • wounds
  • during active treatment
  • increased activity level from moderate to vigorous

Nutritional interventions: fluid intake 

There is no direct correlation between fluid intake and fluid retention. However, adequate fluid intake is critical for overall health and wellness. Fluids play a role in detoxification, helping with bowel movements, urination, maintaining temperature via perspiration, etc. 

Fluid needs and frequently asked questions

Do caffeinated beverages count towards my fluid needs? 

Drinking caffeine has a mild diuretic effect (may cause the need to urinate), but studies show that caffeine does NOT cause excessive fluid losses or dehydration. Nevertheless, it is important to balance caffeinated and non-caffeinated drinks throughout the day. 

What are my fluid needs? 

In general, fluid requirements are based upon a person’s weight. 

Assuming that a person is not losing excess fluids (through sweat, vomiting, diarrhea), fluid needs can be calculated as such:

    • The National Cancer Institute suggests consuming 8–12 cups of fluids per day. 
    • Divide a person’s pound weight in half and that is how many ounces per day they should be consuming (a 120 lb woman would need 60 oz [7.5 glasses] of water per day)
    • Provide 1 mL of fluid for every calorie taken in
    • Provide 25 mL of water for every kg of body weight

What counts as fluids?

Food Item       Water Percent
Apple                     84
Banana                  74
Blueberries             85
Cantaloupe             90
Grapes                   81
Orange                   87
Peach                     88
Pineapple                87
Plum                       85
Strawberries            92
Watermelon             92
Fruit Ice                  86
Jell-O                      93
Broccoli                   91
Cabbage                  93
Cauliflower               92
Celery                     95
Cucumber                96
Eggplant                  92
Lettuce (Iceberg)      96
Carrots                    87
Mushrooms              86
Peppers                   92
Tomato                    94
Broth                       85
Yogurt                     85

Nutritional interventions: dietary fats

One function of the lymph system is to absorb fat. Some studies show that limiting calories from fat to 15%-20% of our overall intake (rather than the typical 25%-35%), may improve lymphedema symptoms. In addition, certain kinds of fats are not primarily transported through the lymph system. These fats are called medium chain triglycerides (MCTs). Studies have shown that consuming these kinds of fats may decrease lymphedema symptoms. Coconut oil is one example of a fat that contains a large percentage of MCTs.

Obesity and lymphedema

Most studies show there is a direct relationship between people who are overweight or obese and incidence of lymphedema. While the exact mechanism is not fully understood, excess weight creates more work for the lymphatic system. The additional fat deposition creates deeper separations in the lymphatic channels. 

In addition, researchers have learned that adipose (fat) tissue is not inactive. It is constantly secreting hormones and markers of inflammation. This inflammation can worsen lymphedema symptoms. In addition, excess weight leads to decreased mobility, likely decreasing the ability to exercise.

There are several strategies for weight management. Focusing on less processed whole foods with simple and recognizable ingredient lists is a healthy way to approach weight loss. This approach helps to maintain the emphasis on nutrient rich, anti-inflammatory dietary patterns. Working with a registered dietitian can also help efforts.

Future directions

Anti-inflammatory foods, immune boosting foods, dietary supplements

Currently there are no direct studies linking specific dietary patterns to lymphedema. However, with the understanding that there is a relationship between lymphedema, the immune system, and inflammation, future studies may find that key foods will help patients decrease edema volume, reduce abnormal blood vessel growth, and improve immunity (see below for a list of foods). It is essential to evaluate patients for adequate intakes of key nutrients, especially those that promote tissue healing like zinc and vitamin C. 

Anti-inflammatory foods/spices

    • Walnuts
    • Curcumin
    • Saffron
    • Ginger
    • Red grapes
    • Lemon
    • Green tea
    • Seaweed
    • Beets
    • Cacao
    • Black currants
    • Parsley
    • Wild blueberries
    • Omega 3 rich fish like wild caught salmon

Immune boosting foods

    • Mushrooms
    • Fermented foods (yogurt, kefir, miso) 
    • Zinc-rich foods (wheat germ, spinach) 
    • Selenium-rich foods (sunflower seeds, brazil nuts) 
    • Ginger, garlic, onions
    • Vitamin D
    • Broad spectrum of phytonutrients from fruits and vegetables

Summary

Overall, most evidence supports the following nutritional recommendations:  

    • consuming no more than 2300 mg salt daily
    • consuming appropriate intake of macronutrients, approximately: 
      • 15%-20% fat  
      • 30%-35% protein
      • 45%-55% carbohydrate

Striving towards and/or maintaining a normal body weight by following a balanced diet and eating a broad spectrum of fruits and vegetables will benefit not just people living with lymphedema, but everyone. 

References:

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Hillary Sachs MS, RD, CSO, CDN is a board certified oncology dietitian working in an outpatient chemotherapy center and as an oncology nutrition education consultant for Meals to Heal, a USA-based company dedicated to providing healthy meals, trusted information and access to oncology nutrition professionals.  She uses evidenced based information to help patients minimize treatment related side effects and to guide survivors towards health and wellness.